- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $151.36 / $1,230.27
| Professional | | $67.61 | $151.36 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $229.09 / $234.42
| Professional | | $208.93 | $229.09 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $269.15
| Facility | | $165.96 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $288.40 / $407.38
| Professional | | $165.96 | $288.40 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $263.03 / $1,122.02
| Facility | | $151.36 | $263.03 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $239.88
| Professional | | $79.43 | $141.25 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $645.65
| Professional | | $263.03 | $263.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $588.84 / $645.65
| Professional | | $331.13 | $588.84 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $158.49 / $245.47
| Facility | | $138.04 | $158.49 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $117.49 / $186.21
| Professional | | $85.11 | $117.49 | $186.21 |